BUPA Insurance Limited · DRN-6225372

The complaint Mr I is unhappy that BUPA Insurance Limited hasn’t fully settled a claim he made on his private medical insurance policy. What happened Mr I claimed on his employer’s group private medical insurance policy which was accepted. It included ECG monitoring. Several months later Mr I received an invoice for around £1900. BUPA said it wasn’t covered because it exceeded his outpatient limit for treatment. Mr I complained to BUPA and the healthcare provider. The provider said it had invoiced BUPA and been told it was Mr I’s responsibility to cover the balance. BUPA maintained they’d acted fairly and said they’d received the invoice from the provider late. However, they reiterated that Mr I had been made aware of the outpatient limit and said it was his responsibility to ensure any treatment fell within it. Unhappy, Mr I referred his complaint about BUPA to the Financial Ombudsman Service. Our investigator looked into what happened and didn’t think BUPA had done anything wrong. He was satisfied Mr I had been made aware of the policy limit and that they couldn’t advise Mr I about the cost of the treatment. Mr I didn’t agree and asked an ombudsman to review the complaint. Mr I referred to a call he’d had with BUPA at a later point in which he was told by BUPA that he should have been advised of the outpatient limit and to keep track of it. He said he wasn’t given the opportunity to make an informed decision about whether to go ahead with treatment knowing that it would exceed the limit. Mr I also said that he’d been advised by the healthcare provider that BUPA did have access to the pricing information and that it was BUPA’s responsibility to ensure that he wasn’t unknowingly exposed to financial risk. So, the complaint was referred to me to make a decision. What I’ve decided – and why I’ve considered all the available evidence and arguments to decide what’s fair and reasonable in the circumstances of this complaint. At the outset I acknowledge that I’ve summarised this complaint in far less detail than Mr I has, and in my own words. I won’t respond to every single point made. No discourtesy is intended by this. Instead, I’ve focussed on what I think are the key issues here. The rules that govern our service allow me to do this as we are an informal dispute resolution service. If there’s something I’ve not mentioned, it isn’t because I’ve overlooked it. I haven’t. I’m satisfied I don’t need to comment on every individual point to be able to fulfil my statutory remit.

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The relevant rules and industry guidelines say that BUPA has a responsibility to handle claims promptly and fairly. And they shouldn’t reject a claim unreasonably. I have a lot of empathy for the circumstances Mr I found himself in. However, I’m not upholding this complaint because: • I’m satisfied that BUPA made Mr I aware of the relevant outpatient limit which applied. It appears in the policy documentation and Mr I was reminded of this during the pre-authorisation stages of the claim. • I appreciate Mr I was subsequently told that he should have been told to keep track of the limit. BUPA has confirmed that’s not their usual process. And, in any event, given that there is a limit on the policy, I think it was for Mr I to ensure that any treatment he accessed fell within the limit prior to committing to it. • I’ve considered what Mr I has said about not knowing what the cost of the treatment would be. The healthcare provider says BUPA would know the rates that applied. However, I don’t think BUPA has acted unreasonably in the circumstances of this case. They authorised the eligible treatment and reminded Mr I of the limit. Mr I didn’t query this with BUPA and whether he may be liable for any of the costs. The ECG was due to take place over a period of two weeks and therefore I think if he had concerns about the costs it was open to him to query this. • Given the volume of claims BUPA handles, and that their role is to let Mr I know if the treatment is eligible under the policy, I don’t think it’s reasonable to have expected BUPA to approximate the cost of treatment and work out if it potentially placed Mr I in breach of the policy limits. That’s not standard industry practice and isn’t generally how private medical insurance policies work. Overall, I’m satisfied that the information provided to Mr I in the policy documentation and the claims process made him adequately aware that outpatient treatment above the limit wouldn’t be covered. • In any event, I don’t think BUPA were aware of the cost of the ECG treatment until after it had taken place. BUPA’s records from their systems show they weren’t invoiced until June 2025. I’ve taken into account the healthcare provider’s letter. I note that it says the invoice was submitted manually as it couldn’t be processed via the platform. And I haven’t been provided with compelling evidence that the invoice for the ECG was submitted and followed up as the healthcare provider has suggested. That’s not consistent with what BUPA’s systems show. So, I can’t safely conclude, on the balance of probabilities, that the delay in processing the invoice was a result of something BUPA did wrong. • I appreciate that Mr I has received conflicting information from the healthcare provider and BUPA. I can empathise with this and understand his frustration. I can’t comment on the actions of the healthcare provider as it’s not within my jurisdiction to do so. However, based on the information presented as part of this complaint, I’m not persuaded that BUPA is at fault in the circumstances of this case. My final decision I’m not upholding this complaint.

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Under the rules of the Financial Ombudsman Service, I’m required to ask Mr I to accept or reject my decision before 23 April 2026. Anna Wilshaw Ombudsman

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